Fever of Unknown Origin

Question 1

What questions do you ask in a history of recurring fever over a month?

Answer 1

• Destination and time spent is essential - informs you of prevalent diseases
• Important to ask about travel preparation including appropriate vaccinations or prophylaxis (such as antimalarials), precautions whilst travelling (mosquito nets, use of spray etc)
• Activities undertaken may expose to specific diseases such as fresh water swimming and risk of schistosomiasis
• Specific questions about other focal symptoms as for any infection

Question 2

What would a clear history of a week without fever mean?

Answer 2

Very reassuring as it makes a more significant diagnosis, such as untreated infection or serious systemic disease, less likely.

Question 3

What can be done if the patient presents with diarrhoea?

Answer 3

In order to identify those infective causes which may need further treatment or monitoring, NICE recommend sending stool for microbiology if you suspect septicaemia, if there is blood/mucus in the stool or if the child is immunocompromised. Also, consider sending stool if there is a hx of travel, the diarrhoea has persisted >7 days or you are uncertain about diagnosis of gastroenteritis.

Question 4

What is Lyme disease?

Answer 4

A tick-born spirochaetial infection caused by Borrelia Burgdorferi. It is the commonest vector-borne infection in the UK and endemic in some areas e.g. the New Forest.

Question 5

What are the features of Lyme disease?

Answer 5

• Initial bite may be painless, unless there is a local reaction or secondary bacterial infection. Early disease with non-specific systemic symptoms such as fever, arthralgia and malaise, often associated with the typical rash (erythema chronicum migrans - ‘bulls-eye’ rash in 80%)
• Few weeks later - aseptic meningitis, facial palsy, arthritis, carditis
• Months to years later - neuropsychiatric manifestations and chronic fatigue (rare in children)

Question 6

What is the management of Lyme disease?

Answer 6

• Can diagnose clinically if bulls eye rash seen and treatment can be given without serological confirmation
• Enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdoferi are 1st line - if negative can do 4-6 weeks after 1st test as seroconversion generally happens after early stage
• Cefuroxime and amoxicillin abx used
• Blood tests indicated if symptoms persist and there is uncertainty about diagnosis

Question 7

What is Kernig’s and Brudzinski sign?

Answer 7

• Kernig’s: Pain on lower leg extension with hip flexed

- Brudzinski: involuntary flexion of the knees and hips with neck flexion

Question 8

What can reptiles transmit to humans?

Answer 8

Salmonella - includes bearded lizards

Question 9

What are the signs and symptoms of Kawasaki’s disease?

Answer 9

• High temp >5days
• Bilateral (non-purulent) conjunctivitis
• Cervical lymphadenopathy
• Swollen red lips, tongue
• Rash - pleomorphic
• Peeling of skin of hands and feet

Question 10

What does bloody diarrhoea suggest?

Answer 10

Bloody diarrhoea tends to suggest bacterial as opposed to viral infection of the intestine, campylobacter is a very common cause of diarrhoea worldwide and illnesses typically last 3-5 days. E. Coli is less common but can cause HUS.

Question 11

Why do children get fevers?

Answer 11

• > 38 degrees in paediatrics (normal is 35.5-37.5)
• A fever helps fight infections by: making our cellular immunological reactions more efficient and making the body’s environment less hospitable to pathogens.

Question 12

What are the causes of fever?

Answer 12

• Infection (most common) - viral, bacterial, TB, fungal (rare)
• Post-immunisation
• Certain inflammatory conditions
• Malignancy
• Environmental in infants aged <3/12

Question 13

How can infections present in young children?

Answer 13

With a low temperature or temperature instability rather than a fever.

Question 14

What questions do you ask for history of a fever?

Answer 14

• When did it start?
• How long has it been going on for?
• Is it constant or intermittent?
• How is the fever being measured?
• What is the measured temperature?
• What antipyretic medications have been given and at what dose?
• What is the response to antipyretics?
• Are there any associated symptoms?
• Is this a recurring problem?

Question 15

How do you manage a viral illness?

Answer 15

• Reassurance given
• Discharged with advice - encourage oral fluid intake and antipyretics as required, return if any further concerns
• Important to safety net - clear instructions given to patients and families, clear documentation of discussion

Question 16

What is severe sepsis?

Answer 16

Sepsis in the presence of CV dysfunction, acute respiratory distress syndrome or dysfunction of 2 or more organ systems.

Question 17

What is septic shock?

Answer 17

Sepsis with CV dysfunction persisting after at least 40mls/kg of fluid resuscitation given in 1 hr.

Question 18

What is the SEPSIS 6: The First Hour?

Answer 18

• Administer high flow O2 using NRB mask
• Obtain IV/IO access and take bloods - FBC, clotting, Group&Save, CRP, blood culture, meningococcal PCR
• Give fluid: 20mls/kg of isotonic fluid (Plasmalyte)
• Give IV abx - commonly ceftriaxone
• Senior review: ask for help EARLY
• Consider inotropic support to maintain BP e.g. adrenaline

Question 19

What is the red flag sepsis criteria for children?

Answer 19

• Hypotension - systolic BP < 2 SD for age, mean BP <2 SD for age (age times 2 + 70)
• HR <30 above normal upper rate limit for age (tachycardia)
• Lactate - > twice the upper limit as normal
• Prolonged CRT >5 secs
• Pale/mottled/blue or non-blanching (purpuric) rash)
• Oxygen needed to maintain saturations >92%
• RR >60 or grunting (tachypnoea)
• AVPU = V, P or U (decreased consciousness)
• Parents report excessively dry nappies, lack of response to social cues, significantly decreased activity or weak, high-pitched continuous cry (parental concern)

Question 20

When would you suspect immunodeficiency in children?

Answer 20

• When children have recurrent episodes of infection outside the normal range - up to 13/yr is normal in infants and young children, these are largely viral URTI
• When IV abx are needed
• When the child has had recurrent deep-seated infections or infections which have crossed tissue planes
• When there is a FH of a primary immunodeficiency (PID)
• When there are indicators of faltering growth
• Microbiology findings may be suggestive

Question 21

Describe immunodeficiency in children

Answer 21

• Primary vs secondary
• Affects up to 1 in 2000 births
• Conditions vary by age at presentation
• 4 main types: B cell (humoral), T cell (cellular), complement issues, phagocytosis problems

Question 22

What are the investigations for immunodeficiency in children?

Answer 22

• FBC with differential
• Immunoglobulins (IgA, IgG and IGM) with subclasses
• Vaccine responses
• Complement levels
• Symptom diary and growth chart

Question 23

What is SCID?

Answer 23

• Collection of genetic disorders with shared phenotype - very low number and insufficient function of T lymphocytes, variable deficiencies in B and NK cells
• Typical and atypical SCID
• Affects 1 in 58,000 newborns
• > 20 identified genetic mutations
• Identifying genetics may lead to improving outcomes by tailoring treatments
• Can test on newborn screening (blood spot test)

Question 24

What are the signs of sepsis in paediatrics?

Answer 24

• Deranged physical observations
• Prolonged capillary refill time (CRT)
• Fever or hypothermia
• Deranged behaviour
• Poor feeding
• Inconsolable or high pitched crying
• High pitched or weak cry
• Reduced consciousness
• Reduced body tone (floppy)
• Skin colour changes (cyanosis, mottled pale or ashen)